Assessing self-reported core competencies of public health practitioners in Lebanon using the WHO-ASPHER validated scale: a pilot study

Background The World Health Organization and the Association of Schools of Public Health in the European Region recommend the self-assessment of public health core competencies to strengthen the proficiency of the public health workforce and prepare them for future challenges. A framework for these competencies is lacking and highly needed in Lebanon. This study aims to validate the WHO-ASPHER self-declared scale and evaluate the perceived competency level of the different categories of Lebanese public health practitioners. Methods This population-based cross-sectional study conducted online between July and September 2021 involved 66 public health practitioners who graduated from different universities in Lebanon. Data were collected using the snowball technique via a self-report questionnaire that assessed public health proficiency, categorized into 1) content and context, 2) relationship and interactions, and 3) performance and achievements. The rotated component matrix technique was used to test the construct validity of the scales. Bivariate and multivariate analyses were performed after ensuring the adequacy of the models. Significance was set at a p-value < 0.05. Results The factor analysis for scale domains showed that the Barlett test sphericity was significant (p < 0.001), high loadings of items on factors, and Cronbach’s alpha values of more than 0.9 in all three categories, showing an appropriate scale validity and reliability. The perceived level of competencies was significantly different between public health professionals and other health professionals with public health activities. All respondents scored low in most public health categories, mainly science and practice. Conclusion Data findings showed variability of self-declared gaps in knowledge and proficiency, suggesting the need to review the national public health education programs. Our study offers a valuable tool for academia and public health professionals to self-assess the level of public health proficiency and guide continuous education needs for professional development. Supplementary Information The online version contains supplementary material available at 10.1186/s12909-022-03940-4.


Background
Public health is an organized societal effort based on different structures and processes intended to understand, safeguard and improve population health and reduce health inequalities [1][2][3]. It is the art of applying science in the context of politics to assess the influences of health systems and interventions on societies' mental and *Correspondence: katia_iskandar@hotmail.com physical health promotion and efficiency, health protection, and disease prevention [1][2][3][4][5][6][7][8]. Public health tackles all socioeconomic, political, physical, chemical, and biological conditions that impact or interact with the population's health [9]. A high-performing public health system requires a competent public health workforce with adequate baseline capacity and transferrable skills to be held professionally accountable for the health of a defined population [9][10][11][12][13][14]. Therefore, a lack of workforce competence contributes to substandard service delivery [15] and leads to social, economic, and health burdens [14][15][16]. Alternatively, strengthening the performance and core competencies contributes to the sustainable development of nations [14,17].
To ensure a high level of proficiency and highlight the gaps in knowledge that need strengthening, self-assessment of core competencies in public health is considered a starting point. The baseline requirements for high-level public health performance and service delivery differ between countries [18]. More than ten frameworks for assessing core competencies in public health are available for use, originating from different countries such as the United States of America (USA), Canada, New Zealand, the United Kingdom, and other European countries [9,[19][20][21][22][23][24][25][26][27][28]. The knowledge and skills needed to carry out core professional functions in public health are complex [9,10,20].
Published studies used mainly a formulated survey to assess the perceived needs of public health practitioners for training and identify gaps in knowledge [29][30][31]. A recent review of the questions asked in 24 published articles showed a lack of consistency, thus limiting the generalizability of the findings [32]. Another systematic review published in 2012 evaluated 126 public health workforce articles and gray literature and recommended the development of quantifiable output measures to offer baseline data to build models that address workforce demand [33]. This finding highlights the need for a country-specific framework for the self-assessment of public health core competencies to overcome these barriers.
Consequently, in the absence of requirements for health workers to receive public health training and the lack of preset national core competencies to assess the competence of the public health workforce, matching population health priorities and professional competencies is very challenging [26]. The World Health Organization (WHO) and the Association of Schools of Public Health in the European Region (ASPHER) set a contextspecific core competency framework designed to assess the gaps and weaknesses in the levels of knowledge, skills, aptitudes of public health practitioners, aiming to strengthen public health workforce [26]. The framework provides level descriptors to interpret the extent to which competencies are mastered based on the Dreyfus model of adult skill acquisition [34]. The WHO framework sets three categories of competency needed to assess the extent of mastered competencies in each domain [26]. Category 1 evaluates the science and practice, health promotion, one-health, and security; it also tackles law, policies, and ethic-related frameworks that reinforce public health practice. Category 2 examines the level of competencies in terms of relations and interactions, such as communication and advocacy, collaboration and partnership, and leadership and system thinking. Category 3 addresses performance and achievements, such as professional development, governance, ethical practice, and resource management [26].
The assessment of competencies offers a broader perspective on how to serve the needs of populations and create people-centered services. It also helps improve the curricula and continuing professional development based on existing capacity and training requirements [26,35].
Furthermore, lessons learned from the COVID-19 pandemic highlighted the gaps in global health systems readiness facing this threat and the need to strengthen the core competencies of the health workforce to deliver efficient public health functions [35][36][37][38]. More specifically, in Lebanon, the pandemic and the Port of Beirut explosion on August 4, 2020, revealed a chaotic Lebanese health system, struggling to manage these concomitant public health crises with limited or lack of resources, drug shortages, a damaged infrastructure, health professionals' migration, and economic downturn [39]. This challenging situation shows the need for a national health system plan for humanitarian crises, relying on a highly competent and trained public health workforce. The public health workforce (PHW) is highly diverse and complex [40], including a broad range of occupational backgrounds trained in a variety of institutional settings involved in the protection and promotion of public health [40].
To our knowledge, little is known about the competencies of public health professionals in Lebanon. Public health education is delivered in schools/faculties of health sciences and/or health professions. Degrees offered can be undergraduate or graduate and can be professionally oriented or research-driven (i.e., to be completed by a PhD). Public health professionals work in public and private sectors (non-governmental organizations and health institutions), while some teach in universities. The only professional association for public health workers in Lebanon is the Lebanese Epidemiological Association (LEA), which has been providing an umbrella to academic and field workers in epidemiology and public health in Lebanon since 1994. However, it does not have guidelines related to the job market of public health professionals and does not give directions regarding national educational needs in the field.
This study primarily aims to validate the public health self-assessment competency scale adapted from the WHO-ASPHER framework and assess the self-declared competencies of Lebanese public health professionals using a validated scale. The results would help determine the gaps in knowledge, prioritize the domains that need strengthening in public health, and identify the national public health educational program needs and necessary competencies for prospective public health bachelor or master graduates.

Study design and sampling
A population-based cross-sectional study conducted online between July 01, 2021, and September 30, 2021, involved 66 public health practitioners who graduated from different universities in Lebanon. Data were collected using the snowball technique via a self-report questionnaire developed on Google Forms (https:// forms. gle/ J4wXj q5sZU BYdqf R7) and shared on social media (WhatsApp, Facebook, and LinkedIn) of healthcare professional groups and public health graduates from different universities (Additional file 1 Appendix 1). Public health graduates and practitioners, healthcare professionals involved in public health activities in Lebanon, and epidemiologists were eligible to participate in the study.

Ethics approval
The Lebanese International University research committee approved this study (2020RC-047-LIUSOP). The objectives were stated on the landing page of the survey, and participants had to consent to participate before enrolling. They received no compensation in return for their participation, which was entirely voluntary.

Sample size calculation
The G-power 3.1.9.4 software [41] calculated a minimum sample of 64 participants based on a Cohen effect size f 2 = 30% (large explanation of the dependent variable by the model variables), an alpha error of 5%, a power of 80%, and considering ten factors to be entered in the multivariable analysis.

Questionnaire (Appendix 1)
The online survey tool was in English and included closed-ended questions. It was inspired by published articles and reports [14,19,25] and adapted by the authors (of whom three are public health experts) to fit the Lebanese context of public health practice. Some items were clarified by adding the geographical location "in Lebanon", while others were removed or adapted to the Lebanese practice.
The questionnaire consisted of four main sections. The first section covered sociodemographic characteristics (age, gender, area of residence, specialization field, public health practice domain, and years of experience). The second section consisted of public health essential operations, and the third section assessed the level of public health workforce competency (detailed below). In the fourth section, public health practitioners gave feedback on their experience by rating 15 statements on a 5-point Likert scale ranging from totally disagree to totally agree. The five options were collapsed into three categories as follows: strongly agree/agree, neutral, disagree/strongly disagree.

Competency assessment section
Competency assessment items were distributed over three main categories, each composed of several domains, as presented by the WHO-ASPHER framework [26]: 1 Content and context. This category encompasses four domains: 1) Science and practice; 2) Promoting health; 3) Law, policies, and health services; 4) Onehealth and health security. 2 Relations and interactions. This category encompasses three domains: 1) Leadership and systems thinking; 2) Collaboration and partnerships; 3) Communication, culture, and advocacy. 3 Performance and achievements. This category encompasses three domains: 1) Governance and resource management; 2) Professional development and reflective ethical practice; 3) Organizational literacy and adaptability.
Participants were asked to rate their perceived level of proficiency on each competency statement in the three categories listed above [26] on a 4-point Likert scale: 1 (none: I am unaware or have very little knowledge of the skill), 2 (aware: I have heard of, but have limited knowledge or ability to apply the skill), 3 (knowledgeable: I am comfortable with my knowledge or ability to apply the skill), and 4 (proficient: I am very comfortable, am an expert, or could teach this skill to others). The average score for each category represents the total number of allocated scores per statement divided by the total number of statements per category. The results represent the average score for all domains. A score of 1-2 per domain means a low level of competency that needs strengthening, while a score of 3-4 is interpreted as a high level of competency [26].

Statistical analysis
Data were extracted from Google on an Excel spreadsheet and analyzed using SPSS version 25.0. A descriptive analysis evaluated the sample demographic characteristics using the absolute frequencies and percentages for categorical variables and means and standard deviations (SD) for quantitative measures.
The rotated component matrix technique was used to test the construct validity of the scales. The Kaiser-Meyer-Olkin's (KMO) measure of sampling adequacy and Bartlett's test of sphericity were calculated to ensure the adequacy of the model [42]. Factors with eigenvalues values of more than one were retained, and the scree plot method was used to determine the number of components to extract [43]. Only items with factor loading greater than 0.4 were considered [44]. Cronbach's alpha was calculated to determine the internal consistency of the scale.
For bivariate analysis, the Chi-square test and the Fisher exact test were used to compare percentages, and the Student T-test and the Mann Whitney were applied to compare means between two groups. The multivariate analysis of covariance (MANCOVA) was performed, considering the competency item per category as the dependent variable and the public health specialty versus others as the independent variable after adjusting for gender, years of experience, area of residence, and area of practice. Adjusted coefficients (beta) and their 95% confidence intervals served to interpret the associations between the dependent and independent variables. Residual plots were used to assess the assumptions of the MANCOVA (homoscedasticity); the linear relationship between the continuous dependent and the independent variables was ensured, in addition to the absence of interaction and co-linearity. In all cases, a value of p < 0.05 was considered significant. Table 1 summarizes the sociodemographic characteristics of the study sample. Participants had a mean age of 29.74 ± 7.57 years, were predominantly females (84.8%), mainly living in Mount Lebanon (59.1%), with five or fewer years of experience (71.2%). Study degrees were distributed as follows: Bachelor of Science (BS) in public health (33.3%), pharmacy (21.2%), nursing (10.6%), nutrition (10.6%), and medicine (3%). The vast majority of the respondents practiced in more than one area (63.6%). The fields of practice included academia (63.6%), research epidemiology (57.6%), non-governmental organizations (NGOs) (47%), Ministry of Public Health (37.9%), and medical settings (36.4%), added to fresh graduates with a degree in public health (21.2%).

Factor analysis of the WHO-ASPHER competency scale
A factor analysis was performed to assess the validity of the public health competency scale and the adequacy of the model.
For the "Content and Context" category, the KMO measure of sampling adequacy was 0.923 for "Science and Practice", 0.924 for "Promoting Health", 0.915 for "Law, Policies, and Health Services", and 0.972 for "One-Health and Health Security". Regarding "Science and Practice", the first factor explained the most variance by 69.97%, followed by 8.71% for the second factor. For "Promoting Health", "Law, Policies, and Health Services", and "One Health and Health Security", the first factor explained all the variances by 76.16%, 81.91%, and 77%, respectively (Table 2A).    Regarding the "Relations and Interactions" category, the KMO measure of sampling adequacy was 0.920 for the "Leadership and Systems Thinking", 0.880 for "Collaboration and Partnerships", and 0.917 for "Communication, Culture, and Advocacy". For the "Leadership and Systems Thinking", "Collaboration and Partnerships", and "Communication, Culture, and Advocacy", the first factor explained all the variances by 85.04%, 83.88%, and 82.94%, respectively (Table 2B).
Finally, in the "Performance and Achievements" category, the KMO measure of sampling adequacy was 0.915 for "Governance and Resource Management", 0.856 for "Professional Development and Reflective Ethical Practice", and 0.918 for "Organizational Literacy and Adaptability". For the "Governance and Resource Management", "Professional Development and Reflective Ethical Practice", and "Organizational Literacy and Adaptability", the first factor explained all the variances by 73.23%, 87.65%, and 87.02%, respectively. In all categories, Barlett's test of sphericity was significant (p < 0.001), and Cronbach's alpha value was higher than 0.9 (Table 2C). Table 3 describes the perceived level of knowledge for public health essential operations. Most participants declared being knowledgeable of the public health essential operations. Almost half of them (48.5%) considered they had adequate knowledge in assuring sustainable organizational structures and financing. Table 4 shows the differences in competency levels between all specialties and between public health professionals versus all the others. Overall, graduates with a BS in public health reported a lower competency compared to other specialties in most categories and domains, with percentages varying by 2 to 4 folds.

Bivariate analysis Competency levels between specialties
In Category 1 (Content and Context), the results showed statistically significant differences between public health versus other specialties in the domains of "Science and Practice" (p = 0.042) and "Promoting Health" (p = 0.005), with the holders of a BS in public health degree declaring being less competent than their counterparts from other specialties. A significant association was found between all specialties and the domains of "Promoting Health" (p = 0.001), where the nursing specialty scored higher than other specialties. In addition, medical doctors showed a higher competency in Law, Policies, and Health Security domain than other health professionals (p = 0.036).
In Category 2 (Relations and Interactions), statistically significant differences in knowledge were found in all domains between all specialties and between public health specialists versus all others (p < 0.05), except for a borderline difference (p = 0.055) when comparing the level of competency in "Communication, Culture, and Advocacy" between public health and other specialties. Public health degree holders declared being less competent than other public health professionals, with nurses being more competent than all others in this domain.
In Category 3 (performance and achievements), the results showed statistically significant differences between public health versus other specialties (p < 0.05), where public health degree holders were also less competent than professionals from other specialties. Medical doctors seemed more competent than other practitioners in the domain of "Governance and Resource Management" (p = 0.005).
However, the results showed non-significant differences in the declared level of competencies in Category 1 (Content and Context), in the domain of "One-Health and Health Security" between all specialties (p = 0.121) and between public health versus all others (p = 0.155). Table 5 highlights the feedback agreement of the participants on the main competencies needed for public health practitioners based on their experience. The vast majority of participants (90.9%) agreed that "having foundational training in a health discipline" is a priority. Less than half of them (43.9%) considered that "performing intuitively and only occasionally need deliberation" is a priority for public health practitioners. Table 6 shows no significant associations between baseline specialties and self-declared competencies, while the latter were sometimes affected by sociodemographic characteristics (Fig. 1).

Multivariate analysis
There were no statistically significant differences between public health practitioners and all others for any of these competencies (p > 0.05 for all).

Category 1 (Content and Context)
Practicing as a research epidemiologist (Beta = 0.412, p = 0.039) was significantly associated with a higher "Science and Practice" score. Female gender (beta = 0.637, p = 0.042) was significantly associated with a higher "Promoting Health" score. Working in the Ministry of Public Health was significantly associated with higher "Law, Policies, and Health Security" (Beta = 0.457, p = 0.022) and higher "One-Health and Health Security" scores (Beta = 0.511, p = 0.012).
Having an experience of 1-5 years (Beta = -0.625, p = 0.016) was significantly associated with lower "Law, Policies, and Health Security" scores. Living in Mount Lebanon was significantly associated with lower scores in all Category 1 competencies.

Category 2 (Relations and Interactions)
Participants living in the Mount Lebanon and North regions scored significantly lower in three competencies (Leadership and Systems Thinking, Collaboration and Partnerships, and Communication, Culture, and Advocacy). Female gender was significantly associated with higher "Collaboration and Partnerships" and "Communication, Culture, and Advocacy" scores.

Category 3 (Performance and Achievements)
Living in Mount Lebanon was significantly associated with lower scores in three competencies (Governance and Resource Management, Organizational Literacy and Adaptability, and Professional Development and Reflective Ethical Practice). Also, participants from North Lebanon scored significantly lower on "Organizational Literacy and Adaptability" and "Professional Development and Reflective Ethical Practice". Being a female (Beta = 0.763, p = 0.024) and having an experience of 6-10 years (Beta = 0.834, p = 0.034) were significantly associated with higher "Professional Development and Reflective Ethical Practice" scores.

Discussion
Our study is the first to validate a tool to assess selfdeclared public health competencies, namely the WHO-ASPHER framework. The framework comprises three categories, i.e., 1) Content and Context, 2) Relations and Interactions, and 3) Performance and Achievements, each divided into domains that include many items. The factor analysis for scale domains showed that Barlett's test of sphericity was significant (p < 0.001), high loadings of items on factors, and Cronbach's alpha values of more than 0.9 in all three categories, indicating appropriate validity and reliability. These results show the possibility of applying a European framework in a developing country, which can be considered an innovation in the Lebanese context in the absence of a national framework. Our results are also close to those of Zwanikken and collaborators, who used Delphi rounds with experts and alumni feedback to validate their framework in lowand middle-income countries [45]; they came up with domains of a different structure than ours, but the content is overall comparable. The WHO-ASPHER framework can thus be used in Lebanon and would also allow benchmarking at the international level. In Lebanon, the suggested framework would thus allow public health professionals to self-evaluate their proficiency level in different domains and determine the gaps in knowledge that need strengthening. Investment in the public health workforce is more highly mandated now than ever [26,46,47]. The COVID-19 pandemic highlighted global weaknesses in the health systems against the threat of communicable diseases and disease outbreaks [26,48]. Consequently, strengthening public health capacity and services has become a global priority [9,26,[49][50][51], and the core competencies in the public health framework allow professionals to reach this goal [26] and help identify the essential individual attributes required to fulfill their role [52,53]. Indeed, the Institute of Medicine (IOM) and other academic, governmental and non-governmental institutions emphasized the need to enhance academic preparedness to meet the 21 st -century public health challenges [51,[54][55][56][57][58][59][60][61][62].
The suggested framework would also help stakeholders, such as policy-makers, educational institutions, and public health institutes [26], develop context-specific competency measures to improve education, performance, capacity-building, analysis, and monitoring, in addition to planning and investment [26]. Our study validated the framework to offer an evidence-based, comprehensive template that helps the public health practitioner identify the domains that need strengthening and guides the academic sector to plan a curriculum that meets current and future public health challenges.
Data analysis of the survey showed that the perceived level of competencies was significantly different between the public health professionals and other health professionals with activities in public health. Graduates with public health degrees declared a lower competency level than other health professionals; the latter had variable competency levels in different domains, depending on the health specialty. It is noteworthy that multivariate analysis showed that differences were no longer significant, likely due to the low sample size.
Our findings also revealed that public health core competencies and workforce requirements are not yet well delineated at the national level. All respondents from different educational backgrounds scored low in most public health categories, mainly science and practice. Other studies reported similar results, highlighting the need to call for action to build a public health workforce [56,63,64]. Most participants agreed that foundational training in a health discipline is the main competency needed for public health professionals. These findings shed light on the existing capacity and future training requirements to strengthen education tailored to national needs [26].
Studies similar to ours using a formulated framework or survey showed that the main gaps were communication, budgeting and financial planning [29][30][31], systems thinking [30,31,65], policy development [29,65,66], and other management skills [29,31,65] among surveyed    participants. Other gaps included developing a vision for a healthier community [30]. The level of competencies was significantly different between public health professionals and other health professionals with activities in public health. Creating a public health workforce that delivers essential services in all domains of the three core competency categories is critical and challenging at the same time. According to the WHO-ASPHER, professionals are expected to demonstrate a subset of their competencies related to their role [26]. This study offers baseline data to conduct in-depth research across Lebanon, including public health professionals from multiple disciplines and universities with variable levels of expertise and practice in the In the global model, the independent variable is "specialty" (public health vs others*). Covariates are gender, years of experience, area of residence and area of practice a Reference group Fig. 1 Adjusted means of health competency domains according to the type of specialty (public health vs. other specialties). No significant difference between public health and other specialties in self-declared competency domains with p > 0.05 field. Based on these findings, building a highly-performing Lebanese public health workforce, linking education to practice, and enhancing cross-disciplinary collaboration would help design an academic curriculum for excellence in public health practice. This study also highlighted the importance of setting national guidelines for public health workforce planning and policy-supporting workforce development while addressing the gaps and pitfalls in the field. The guidelines should be tailored to the local requirements to set targeted objectives and plan a joint action based on the adapted WHO-ASPHER framework to the national context. Other countries can benefit from this framework to allow benchmarking, follow-up, and collaborative international action plans for health policy-making to improve competencies in public health. This study would be the ground for identifying workforce misdistribution, inefficiencies, performance evaluation, and quality assurance to build a workforce for excellence. To reach this point, strategies related to public health education and the workforce are necessary, based on further assessment of the Lebanese context; authorities, academia, professionals, and other stakeholders should join efforts to develop and implement such strategies.

Strengths and limitations
Our study is the first to validate the scale for self-assessment of public health core competencies. It offers a valuable tool for academia and public health professionals to self-assess the level of public health proficiency and orientate continuous education needs for professional development on an individual level while also offering evidenced data for curriculum review and identification of training needs in the academic sector.
The main limitation of this study is the low number of participants per specialty; thus, larger-scale studies are warranted to confirm these descriptive results. The survey was web-based, which may be amenable to sampling and response bias, given in particular that the population of public health professionals is large and unclearly defined. Moreover, when diffusing the questionnaire on social media, most accounts were open; thus, the exact number of potential participants who received the survey link could not be assessed. Respondents were mainly females with one to five years of experience, which hampers the generalizability of the results. Participants self-rated their level of competency in public health services, reflecting their perception only and leading to reporting bias. However, the study design and method used are common to other tool validation studies.

Conclusion
Our study offered a validated tool for academia and public health professionals based on the WHO-ASPHER framework to self-assess the level of public health proficiency and guide continuous education needs for professional development. Data findings also showed variability of self-declared gaps in knowledge and skills, suggesting a need to review the national public health education programs. This study calls for close collaboration between academia and health policy-makers to strengthen public health by addressing national gaps and needs while joining forces with international health organizations to improve the global readiness for future health hurdles.